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0128 CRANBERRY LANE - Health
128 Cranberry Lane Barnstable A = 234 066006 ';j ✓ u ., '- - , � III Commonwealth of Massachusetts t k•� 6' Title 5 ®fficialInsYpe`ct on form . x aF . Subsurface Sewage Disposal System Form=Not for,Voluntary.Assessments Jai - - 'Y 'A * ' i.• 128 Cranberry Lane,-6ertteM Le In234 P-G6-6 Property Address r Robin Sexton-Neisius Z;3 �'C) Owner Owner's Name R. information is required for every 128 Cranberry Lane, Centerville "� .,: x� MA 02632 .• it August 30, 2012 page. City/Town • 4 '-'.State {Zip Code Date of Inspection Inspection results must be•submitted on this form. Inspection forms:may not be altered in any way. Please see completeness checklist at the`end of the form. a= ` Impgrtant:Wh utformsen A. ,A General Information fillip ' � • ,," .# •�. on the computer, .• p + use only the tab 1. Inspector:. key to move your cursor-do not Tro Williams use the return Name of Inspector "t key-• .� �; �• • " , Troy Williams Septic Inspections 'ICE Company Name 19 Hummel Drive Company Address South Dennis. �� _ ,, "MA y�' '� t��,_ 02660. City/Town f ,` �, State Zip Code ' (508) 385- 1300 _ Y.. SI682 .' Telephone Number a License Number B. Certification 7 I certify that I.have personally inspected the'sewage disposal system at this address and that the information reported below is true,accurate and.complete as of the time of the Inspection. The inspection was performed based on my training and experience,in•the proper function and maintenance of on site , sewage disposal systems. I am a DEP,,approved system'inspector pursuant to Section 15.340 of k Title 5(310 CMR 15.000).The system: • ` ,4, *. ' ® Passes d ;.,� r_ ❑ ,Conditionally Passes y,s r ❑ -Fails Al El Needs Further Evaluation by.the Local�Approving Authority ;t _� August 30, 2012 Inspectors Signature/*' • Date ' , h The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of.Health or DEP)within 30 days of completing this inspection. If the system is a shared system or ` has a design flow of 10,000 gpd or greater;the inspector and the system'owner shall submit the report to the`appropriate regional office of the DEP: The original should be sent to the system owner `and copies sent to the buyer, if applicable; and the approving authority. ` ""'This report only describes conditions at the time of inspection and undei the conditions of use at that time.This inspection does not address how the system will perform in.the future under, the same or different conditions of use. o t5ins•'11/10 ' y Title 5 Official 1 s pFor.m: urface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts 7` Title. 5 Official Inspection Form Subsurface Sewage Disposal System'Form Not for:.Voluntary Assessments 128 Cranberry Lane, Centerville a - . ,, ' ` M-234 P-G6-6 Property Address ' Robin Sexton=Neisius Owner Owner's Name a information is 128 Cranberry Lane, Centerville 1m MA , 1- 02632 k required for every � ,# August 30, 2012 page, City/Town State a- Zip Code Date of Inspection B. Certification (cont.)' x$�ri'. Inspection Summary;,Check A,B,C,D or E/always complete all of Section D ° ' A) System�Passes ® I have not found any information which indicates that any of the failure criteria described indicated below. exist`Any failure criteria not evaluated are In 310 CMR 15.303 or in 31 0 CMR 15.304" Comments: , System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found a at the time of inspection only. °' L B) 'System Conditionally Passes:Y ❑ One or more systemcomponents as described in the"Conditional Pass" section need to be µr replaced or repaired,The system, upon completion of the replacement or repair, as approved by the Board of Health,-,will pass. _ 4f Check the box for"yes",..no or"not'deterrnined",(Y; N, ND)for the following statements. If"not determined,',please explain The septic tank is metal and over 20'years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial-infiltration or•exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with.a complying septic tank as approved by the Board of -.Health. x *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑°No Y' . ❑_:ND(Explain below):. , N/A 6 w t5ins•11110 1 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts i Title 5 Official 'ln specti®h Form -,- . . ` Subsurface Sewage Disposal System Form -Not for Voluntary..Assessments " 128 Cranberry Lane, Centerville « M -'234� P'-G6-6 Property Address ' . Robin Sexton-Neisius Owner Owners Name tf �. information is a ' 128 Cranberry Lane, Centerville MA : 02632` r 'August 30; 2012 required for every ry 9 page. Cityrrown „-State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ` El Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken; settled or.uneven distribution box. System will pass inspection if(with approval of Board of Health): . . t ❑ broken`pipe(s) are replaced r N ❑4 Y ` :❑ N f '[],.,ND. (Explain below): 0 obstruction is removed =' ❑`Y N ❑ ND(Explain below): distribution box is leveled oreplaced' ❑ Y .❑ N ❑ 'ND (Explain below): "ElN/Air o El S The system required pumping more than 4.times a year due to broken or,obstructed pipe(s). The, system will pass inspection if(with approval of.the Board'of Health): ❑ broken pipe(s)are replaced ❑ Y• ❑ N 0 ND(Explain below): obstruction t{ • - ❑ `;� tion is removed°. Y• ❑ N ❑ ND(Explain below). a N/A k•• C) Further Evaluation is Required by.the Board of.Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is-failing to protect public health, safety or the environment: ' 1. System',will pass'uss Board nle of Health determines in accordance,withe310'CMR « . 15.303(1)(b)that the system'is not functioning in a manner'which will protect'public health,' ` safety and the environment: ❑ " water Cesspool or privy Is within 50 feet of�a surface' El Cesspool or privy,is within 50 feet of.a bordering vegetated wetland or a°salt marsh { , t5ins•11/10 +- "t • , « ;. :' Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17 CIN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °f 128 Cranberry Lane, Centerville y , M-234 P-G6-6 Property Address , Robin Sexton-Neisius Owner Owner's Name information is 128 Cranberry Lane,Centerville MA 02632 ' August 30, 2012 required for every 9 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has"a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: * This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered._A copy of the analysis must be attached to this form. 3. Other: r D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each.of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool E ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 , usetts Commonwealth of Massach "title 5. 0fficial 'lnspe6tion1 Form- Subsurface Sewage Disposal System Form=Not forYoluntary Assessments V•y� 128 Cranberry Lane, Centerville M =234 P-G6-6 Property Address Robin Sexton-Neisius r Owner Owner's Name ' information is 128 Cranberry Lane, Centerville MA 02632-y August 30, 2012, .,required for every 9 page. City/Town °State Zip Code , Date of Inspection B. Certification (cont.) . ry Yes No r. " 0 ®` Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).•Number of times pumped: '❑ - t ® Any portion of the SAS, cesspool or privy is below high ground water elevation. i 'y Any portion of cesspool or privy is within 100-feet of a-surface water supply or tributary'to a surface water supply.- El- F= ® " Any portion_of a cesspool or privy'is within a Zone 1 of a public well. El ' ° ® - Any portion of a cesspool or privy is within 50 feet of a private water,supply well. ® ;Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This • - > -, system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence x of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and'chain of custody must be attached to this form.] r ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000 pd. . The system fails. I have determined that one or more of the,above failure criteria exist as described in 310 CMR 15:303, therefore the system fails. The system owner should contact the Board of Health to determine what will be - necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a ° design flow of•10,000 gpd to 15,000 gpd. For large systems, you must indicate either yes or no to each of the following, in addition to the questions in Section,D. .• Yes No. ` Cz El system is within 400 feet of a surface drinking water,supply r❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El z the system is located in a nitrogen sensitive area(Interim Wellhead Protection ❑ Area—iWPA)or a mapped Zone Il of a public water supply well , If you have answered"yes"to any question in�Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall"upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate, regional office of the Department. s y . ' t5ins•11/10 e Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 r ' L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Cranberry Lane, Centerville M-234 'P-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is 63 128 Cranberry Lane Centerville 'MA 022 August 30, 2012 required for every page. Cityfrown 'State Zip Code_ Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No 1 ® ❑ Pumping.information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ®. Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® - ❑p+ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has " been determined based on: ® ❑ Existing.information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN,flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts w , Title 5 official Ifspection Form" ', ;. Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments y< 128 Cranberry Lane,CCenterville ~ a M-234 P'-G6-6 r - Pro Address; Property + . r Robin Sexton-Neisius Owner, O - wner's Name info rmation is required for every 128 Cranberry Lane, Centerville ,� _..; MA 02632 August 30, 2012" page. Cityrrown -' • .State Zip Code° ";Date of Inspection D. System Information q {. 4 Description: Number of current residents: r ''`, ,5 Does residence have a.garbage grinder?, f, El Yes > No Is laundry on a separate sewage system?•[if yes,separate inspection required]: ❑ Yes ® No Laundry system inspected? ® Yes ❑ '� , No • Seasonal use? ,a ;;� - i s, ❑eYes ® No " Water meter readings, if available last 2 ears usage d t 11=148,000 gals. 9 ( Y 9 (9P )) ° r `r 10=132,000 gals. Detail: . Sump pump? t ❑ Yes, ® No A. - - 'Last date of occupancy. - .occupiedDate CommerciaUlndustrial Flow Conditions:;µ , ksyh N/A .Type of Establishment: - Design flow(based on 310 CM14'15.203): ry • N%A ' Gallons per day(gpd), Basis of design flow(seats/persons/sq,f ;etc.): Grease trap present? , . t, a , * F, M. Yes El No' Industrial waste holding tank present? ❑ Yes ❑` No Non-sanitary waste discharged to the Title 5 system? ❑ -Yes ❑ No Water meter readings, if available: t5ins•11H0 a Title 5Official Inspection Form:_Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 128 Cranberry Lane, Centerville ` { M -234 P-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name !information fo is 128 Cranberry Lane Centerville MA 02632 ' August 30, 2012 .required for every ipage. City/Town State Zip Code Date of Inspection D. System Information (cont) ,. Last date of occupancy/use: N/Ary Date Other(describe below): General Information Pumping Records: Source of information: No pumping info was available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy M ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts •°f h ,. � Title 5 officialInspection Form to Subsurface Sewage Disposal System Form -Not for:Voluntary Assessments 1{ •'' 128 Cranberry Lane, Centerville`: ,M -234 P-G6-6 Property Address •.. , a Robin Sexton-Neisius Owner Owner's Name information is 128 Cranberry Lane Centerville�.. -" MA 02632c_ . °Au ust 30.201' required for every _� , page. Cityrrown State Zip Code Date of Inspection D. System"Information (cont.) x { Approximate age of all components,.date installed (if known)and source of information: D-box and leaching were installed to existing tank on 10/27/09 per compliance: Were sewage odors detected when arriving at-the site?,%. b - ;E Yes No Building Sewer(locate on site-plan), 1,2 ' i; •x ` Depth below grade:' r. feet+ 4 '` Material of constructions cast iron g ®40 PVC F. ❑ other(explain) Distance from private water supply;well or suction lines' N/A ` r r feet• i . Comments on condition of joints-�ventin evidence leakage- etc.)'' ( 1 9� 9 • Flushed lines and found clear at the time of inspection. s . r Septic Tank(locate on site pianp .Depth below grade:, feet .. f . Material of construction ` C. ®,concrete 'metal` ; -, ❑fiberglass' ❑`polyethylene ❑ other(explain) - • rt1 r ' • • - - • _ If tank is metal; list age: >A f + .years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes ❑ :No , k ;Dimensions: 3 5'X9'X6'•1000 gallon • ` Sludge depth:_ . . 411 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yy� 128 Cranberry Lane, Centerville M -234 P-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is required for every 128 Cranberry Lane, Centerville MA- 02632 August 30, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21 81t, Scum thickness Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Pumping of tank of this time is recomended. rGrease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A "N/A Dimensions: Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•11/10 # , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts L Title 5 O ic.ial Inspection''Form Subsurface Sewage,Disposal System Form -Not for Vol untary,Assessments- 128 Cranberry Lane"Centerville s M =234'`�P-G6'-6 rY Property Address a t: # ': k 8 Robin Sexton-Neisius > ._ O P'�. Owner Owners Name r information is a required for every 128 Cranberry Lane, Centerville MA - `02632,, August 30,2012 page. Cityrrown State t 'Zip Code Date of Inspection D. System Information (cont:)' x Comments(on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as.related to outlet invert, evidence of leakage,--etc N/A Ti ht or Holding Tank tank must be pumped at•time of inspection) locate on.site Ian : . 9 .9: ( P P P ) ( ;P ) Depth below grade: f 1 ry s „` N/A , r ; 1 r ;; *, .IF Material _ - a of construction. '� � ,�• r -, ❑ concrete 8 ,E] metal ❑fiiberglass- i _❑ pol eth'lene i y y * ❑other(explain):' Dimensions: - Capacity: A i x. ?: " 1 N/A ,h' gallons Y .Design Flow: r �, ., .., - y gallons per day " Alarm present: . El Yes El No ' d a AlarmYaevel. F Alarm 1n working order. ❑ Yes' ❑ No Date of last pumping; * ` { Date / Comments(condition of alarm and float switches,,.etc.): _ a N/A' 4 4 #tip •� ,P L a ,- *Attach copy of current pumping contract(required)'Is copy'attached? ❑ Yes ❑ No t5ins•11/70 F v -Title 5 Official inspection Form.Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection i=orm Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 128 Cranberry Lane, Centerville M -234 P G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is required for every 128 Cranberry Lane, Centerville MA 02632 'August 30, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level.above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with equal distribution to outlet lines through speed levelers. No evidence of solid carry-over or backup in the past were found at the time of inspection. ti Pump Chamber(locate"on site plan): , . Pumps in working order: - ❑ Yes ❑ No Alarms in working order: •` ❑ Yes ❑ No Comments(note condition'of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): ' k , If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official lnspe"ction 1=or� Subsurface Sewage Disposal System Form-`Not for Voluntary Assessments 128 Cranberry Lane, Centerville ;. ; M -234 P-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is f required for every 128 Cranberry Lane, Centerville'* °MA'+.• 02632. n August 30, 2012 page. Citylrown State ^ ' Zip Code Date of Inspection D. System Information(cont.) , Type:El S leaching pits ,. f` number: •,�' ®, leaching chambers number 3-500 gallonwith stoneET r 33.5'Xl TX 2' 1 leaching galleries number. .. - ❑ Teaching trenches number; length: • ❑ leachingfields- numb r i, e dimensions: ' 'I ,� » ❑ overflow cesspool - w. ,number: � •.,. ❑ innovative/alternative system-.; Type/name of tectinology:Y 9 �m Comments(note condition of soil,,signs of hydraulic failure,level ofponding, damp soil,'condition of vegetation,,etc.): » » Chambers were found with little water present at the time`of inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. r3 . Cesspools.(cesspool must be pumped"as part of inspection) (locate on-site plan): Number and configuration ` T a N/A Depth—top of liquid to inlet invert Depth of solids layer , Depth of scum layer ;, N.» Dimensions of cesspool ` Materials of construction N/A - Indication of groundwater inflow :» ❑' Yes ❑ No t5ins•11/10 d;r,c ,`Tiile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts r X r Title 5 Official ,Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Cranberry Lane, Centerville r M 234 P-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is required for every 128 Cranberry Lane Centerville_ MA_- 02632 August 30, 2012 page. Cityrrown 'State Zip Code, Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A N/A Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A , t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 , J I . Commonwealth of Massachusetts Title 5 official - Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Cranberry Lane, Centerville * M -234 ,P'-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is 128 Cranberry Lane, Centerville MA 02632` August 30, 2012 required for every ry �, page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent'reference landmarks or benchmarks. Locate all wells within 100 feet..Locate, where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately, " 1, r - - - - - t A • O. i t5ins•11/10 `, Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Cranberry Lane, Centerville M -234 P-G6-6 Property Address Robin Sexton-Neisius Owner Owner's Name information is required for every 128 Cranberry Lane Centerville MA 02632 August 30, 2012 page. Cityfrown sState Zip Code Date of Inspection D. System Information (cont.). Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells r w # 20.0'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date M ® Observed site(abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: AIW 247 Zone C 24.5' 5.1'adjustment You must describe how you established the high ground water elevation: Hand augered 5.5' below bottom of leaching with no water found.at a depth of 95. Groundwater adjustment at the time of inspection was 5.1': Bottom of leaching at 4.0'was found not to be located in the high groundwater elevation at the time of inspection. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 " Commonwealth of Massachusetts Title 5 official. Mspection -Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Cranberry Lane, Centerville' M-234 P-G6"-6 Property Address Robin Sexton-Neisius ". _ Owner Owner's Name F ' information is required fore very 128 Cranberry y Lane, Centerville MA. :02632° • F-"August'30, 2012 page. Cityfrown State, `;Zip Code' Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C,+;D, or-E checked ' ® Inspection'Summary D(System Failure.Criteria Applicable to All Systems)completed, ® System Information .7 Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page.15 or attached in separate file r • a d-f t5ins•11/10 -- y 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 uN DcrTEcrale Jr- rr; / i T., V7a0i` z _ y SMOKE DETECTORS REVIEWED TAB E�BUILDIND DEPT. DATE FIRE DEPARTMENT D TE ' BOTH SIGNATURES ARE REQUIRED FOR PERM WINO lk WIAI '- E�J .. JL- r F I k ✓ -- Q _ - --- __.. . .__ ..... 5 - 0 _._.. I (?f?cA/ fC c 2c V 04 i i I N ... I j I/ c' > Town of Barnstable �t1HE r P� Department of Regulatory Services � �rAe Public Health Division Date MASS. 9� 1639. `0� 200 Main Street,Hyannis MA 02601 ArED MA't A _ , Date Scheduled ` Time f 0kM Fee Pd. $100,00 Soil Suitability.Assessment for Sewage Disposal Performed By: Brian G.Yergatian, PE, LEED AP Witnessed By: PON AL.0 DESTKA`LAB 31 ?,.S, LOCATION & GENERAL INFORMATION Location Address 128 Cranberry Lane Owner's Name Richard Neisius& Robin Sexton Centerville, MA 02632 Address 128 Cranberry Lane Assessor'sMap/Parcel: 234/066/006 Engineer's Name BSC Group, Inc. NEW CONSTRUCTION REPAIR X Telephone# (508)778-8919 Land Use Residential Slopes(%) Surface Stones Distances from: Open Water Body ft tPossible Wet Area ft Drinking Water Well P1 ft Drainage Way ft Properly Line ft Other ft - O v SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximlt�to holes) r - - 234086009 co r s .234066006 128 234018 B00 . '= 234088007 -• " q0 234066005 N122 234068008 41 0, 81 Fe St � �,... 234086002 k 131 004 D4066003 G<rRc,�at, (A , Parent material(geologic). 0WVU)Q �•S EA Depth to Bedrock /� Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face N�A u .- Estimated Seasonal High Groundwater aJ (C36T---OVA OF �AO G�) DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: " w ' Depth Observed standing in obs:hole. " N I A, in. Depth to soil mottles: N A in.-. ± Depth to weeping from side of obs.hole: W A in. Groundwater Adjustment N 16 ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level- PERCOLATION TEST Date g`17-04Time ll%30 Observation Hole# I Time at 9" ® ' o 11 Depth of Perc x b' Time at 6 ® ' a Start Pre-soak Time @ . " 0 '06 Time(9"-6") K I N S End Pre-soak 6 - I Y Rate Min./inch Site Suitability Assessment: Site Passed X Site Failed: Additional Testing Needed(Y/N) N Original: Public Health Division Observation Hole Data.To Be Completed on Back----------- ***If percolation test is to be conducted within 100'. of wetland,you must first notify the , Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTIC\PERC FORM.DOC DEEP OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 7 SawV k LoaM to M at ab - ta5 G CAAtvS'E Sale O 6 RAN El, Na w,',-rErz o(3SErL.VE1� ND 9XID OX P DEEP OBSERVATION HOLE LOG Hole# 01 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel)_ 0-9 A P SmAt i l.oAV\ YQ a 9 -a6 '(3� Saar k tAAM �o 'CR 5`S 06 -gas G cokesa SAND a.SY Y3 6Z"rU &, (4[30C,FS Na W K-FER 0as of Ve o N0 6,6 cK 06SERM\►E0 DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon - Soil Texture Soil Color -Soil Other { Surface(in.) ' (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravely DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No Yes RX Within 500 year boundary No 'X� Yes Within 100 year flood boundary No Q Yes *, Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the = area proposed for the soil absorption system? rE S If not,what is the depth of naturally occurring pervious material? Certification w I certify that on 10 oZ 06 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with r the required train• g,expertise and experience described in 310 CMR 15.017 _ Signature Date SAV 09 Q:\SEPTIC\PERCFORM.DOC " -n Town of Barnstable �t►+E row Regulatory Services ti Thomas F. Geiler, Director BARNSTABLE, Public Health Division 9Q i6Sq 10� DArEo39.�A Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 10/2 7/2 0 0 9 Sewage Permit# 1 Assessor's Map/Parcel 2 3 4/0 6 6-0 0 6 Installer & Designer Certification Form Designer: BSC GROUP, - INC. Installer: , IQ i�)Jez Address: 349 Route 28, Unit D Address: 3j`Q Vl/1(,t W. Yarmouth, MA 02673 On c �atj��oR� &�was issued-'a permit to install a ` (da e) (installer) septic system at 128 Cranberry Lane, Centerville based on a design drawn by (address) BSC GROUP, INC. dated 9/23/2009 ' (designer) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local-Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required was inspected and the soils were found satisfactory. jN of V G. YERGATIAN Alleignature) G�y1L ca No.462IGISi10 -a�ature (Affix De amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formsWesignercertification form.doc I ��: TOWN OF BARNSTABLE° LOCATION /jb b Ad t r LAAJ6 SEWAGE# O()J 31 ,. VILLAGE c,f n S OR'SrMAP&PARCEL 2�., -d v Lac INSTALLER'S NAME&PHONE NO. 8AJ64J, r6& SEPTIC TANK CAPACITY EMSrl n /6a0 y j./ LEACHING FACILITY:(type) y4k.,Wls (size) 13 33.5 7X 1, NO.OF BEDROOMS OWNER A.. AUE J.S JOSI PERMIT DATE: j®''/'�''�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site"or within 200 feet of leaching facility) feet ` Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facil' ). feet FURNISHED BY _t 5 Ali; I c3- ' I 2 �1— � No. � r - Fee f9(� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi!5ponl 6pgtem Cou tructiou Permit Application for.a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Addr s or L N .IR00 C a� rt+2y �4w e, Owner's Name,Address,and Tel.No. j&\Uak �'e�51Vs r.�Assessor's Map/ParceIC 04 00b `b- Ail— Cme0p il— 8y c(5�� I�oy4 g es Installer's Name Address,and Tel.No. Designer's Name,Address and Tel:No. Blue LuO—&-L Type of Building: Dwelling No. of Bedrooms Lot Size 7�(p sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date $��N,L Z 3, Z 00cl Number of sheets Revision Date Title 4Sfw pS 2�C,66t Q Size of Septic Tank (vim Type of S:A.S. (e V �.C- P. Description of Soil©" 4-0 t� A p ScatJ,r 1L,"w. 9" 4o -e& 13. Nature of Repairs or Alterations(Answer when applicable) VSe !E4 1S�dM 1(?o-0 Q,716m11 GeP�ftY-teu ' IAJSi 0 IS)_z,eJ-C A—L-4 L7Q oS5 4Aa) wi4e,JL �;,QjZ►,.'c e 1"Gi l k 6-6 v ccu a-e L ►��'>t-tom ��,�.►.e �6t c+,nc�,a.d �l�o:r4 Date last inspected: Agreement: , The undersigned agrees to e sure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o tie 5 of the En nmental Code and not to place the system in operation until a Certificate of Compliance has been issued by .i Board of H Signed Date '9 z O°I Application Approved by .S Date /U 1,1 ®1 Application Disapproved by: Date for the following reasons .. Permit No. Date Issued No. 2 f Fee /bO ° THE COMMONWEALTH OF-MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN 0 RN STABLE, MASSACHUSETTS Yes ti 0Lppgtcattou for �Mpoi l *p6te-M Con0tructton Permit Mf � Application for a'Permit to Construct O Repair(.ol"Upgrade O Abandon( ) ❑ Complete System ❑Individual Components yi AJ`-i5luS Location Address or Lot—N�o.Ip�� C. � n+2y �4ti-C. Owner's Name,Address,and Tel.No.Le�liA Assessor's Map/Parcel Old 00 - _ �c�z- dui V oy4'+S a Sae CZOLOO �t Y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � Blue t "i� • C(7�6'+-1Z3-Z #7% 50`6,—T'7�6- 35o R+ 45'Im11,144 w°44404avI w, q QaA"- 244, R V4A:A1 6 w.J t� Type of Building: - - Dwelling No.of Bedrooms . Lot Size sq. ft. Garbage Grinder ( ) Other '-Type of Building No.of Persons Showers( ) Cafeteria( )' Other Fixtures Design Flow(min.required) I/b �6gpd Design flow provided gpd Plan Date$r(F�,c,�,.rz 2?. 2IX1G Number of sheets ,E Revision Date Title S�•6�aC tl],tlJ n.S . SVS c v� c 0'" 'e2 v Size of.Septic Tank Type.of S.A,S. 6 `/G L.C- P. '--- Description o€Soil 0" C) ti A p 9" 7c&" 13w ?(", io 1?4!;- Cdrrnsc su�,� w 1 xn..,,p � F Ca6h I-.S Nature`of,Repairs or Alterations(Answer when applicable) 0.�Q I,V51 I ° 6L.PJ-C WkLLA C0055J ItJL G.180:L tNs4�.t1 l �\ AM w° 4. "19o-1- 411 f Aov,nok ,-AoA /0115�.a�.a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o�jf ttitle 5 of the Envid nmental Code and not to place the system in operation until a Certificate of Compliance has been issued by "his Board ofHedIth. f Signed l / Date q�/z1,/0 q Application Approved by 1/I Gib O Date /O 113101 I Application Disapproved by: / U Date t " for the following reasons V 1` Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded ( ). Abandoned( )by ,_e_,n Q_e-Q-e-S-S 1. J n at �?Fi ( ,n,,,n\n�nn.I I G.� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z 00,7 dated 10113/4/. Installers 4c -, I:Z0AV Designer 95C.. CytRe00 #bedrooms Approved design flow,\ —77e-- gpd The issuance of this permit shall not be construed as a guarantee that the`system wibl function as designed. Date Inspector /Uf Ij ° . No. --Fee .1.b�.�-..--•------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS - - =t!6Po�Ar"AZ)p5tem Coort5tructton Perth Permission is hereby granted to Construct ( ) Repair (,/ ) Upgrade ( ) Abandon ( ) System located at 1 Z`6 C tt c.-A b. n A.l I cl,n. -e t t and as described in the above Application for Disposal System Construction Permit,The applicant recognizes his/her duty; to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date /Q 113/ Off' Approved by � .� COti1N40N11-E".-%LTH OF N kSSACHt'SETTS ' a EXECUTIVE OFFICE OF ENN1RONME\*TAL,AFFAIRS ^, DEPARTNIENT OF E.N%*IRON�,IE\TAL .PROTE,,CTION ONE WINTER STREET. BOSTON. LtA 0210510 `61 f 'S_•� {{ "* , %;ILL1AM F.WE-.D rowN 1998 Tr Y cc,. Gave:ne ARGEO PALL CELLUCCI - ?. _ D. L�,L Gave:= SUBSURFACE SEWAGE 4,!SPOSAL SYSTEM INSPECTION FO �' ornri iss;c r f 4 �����0� �C/1?�5����``CERT1FiCJlTlOtr � •. • _ . Property Addres,, Address of Owner: S4V►Y\ Date of lnspeC.ion: :�. •� ��� CiZV )Z; (If different)' :' Name of Inspector. I D C�c{ro - 1 am a DEP ap roved system inspector pursuant to Section 13.340 of Title S'(310 CMR 15.00015 Company Name:�/Zc '-� Mailing Address:. �O opt �3�? //7!5:NOS H /eI- 2E q Telephone Number. _57e2�2 CL 4!;L— Zy CERTIFICATION STATE'AF\T I cer.:� that I have pe-sonalh inspected the sew'aee,d!i,csal.•systern a-t this address and that the information re:creel below i1 true. ac_ur,:e and ccmole!e as o=the time of inspez-01% The inspeaxn was pe-iormed based-* on my training and experience in the Proper fun:=;Cn a-c maintenance &on-site sewage disposa; systems. The mien.: { _ Co-c1t-onaiiv False! _ Furthe- Ev'aluanom Ey:the Local Apwaving Aufhcrtm -- Fa•'s , Inspecior's Signatur Date: l 7:ie Svi-.e-r Irsyco• sha'' submit a copy of this inspee.,on re3c:. to the Apvcving Authcrim. within thirzv,.(30i days cf c-.m„pieting this insDe::icn. It the sv!iem is-; share= sv'stern a• ha- a dev n flow of 10.000.grc or greater„the tnspe_cr and the sys:e- c•yr,er s~a I su�r :: the re.e- tc the a.crccnate reg'ona► n ice of'the-Depa-ment of Envircnmeriu' Froteciar.. The crigma! should be sent tc the sysiem, c_,� and ccoles :--: to the buyer, ii.applicatle. and the aperoving authorin INSPECTION SUMMARY: Check A, E, AI SYSTEM PASSES: 1 have net fcund any information which indicates that the system violates any of the'failure criteria as define: in ?10 C"R 1 Any failure criteria not evaluated',are indicate+ below. M CO ,tiiENTS: --tHn us c P uTl ack� P w%,V1 t4ltl_ cl a 4 N 01_(NIA_L III SYSTEM CO-NDITIONALLY PASSES: One or more s. tem.eom . P approved • , - p - c ys portents as described in the''Conditional Pass' section neea to be re laia►a or re err?. The sy ste^ , u completion of the replacement or:re air, as roved by the Board•of Hnith, will pass. Indicate yes, no, or not determined'N N, or NOt' Describe basis of determination in III instances I( t determines-, explain w ty ncr. The septic tank is metal; unless the owner or ape:ztor has provided the system inspectorr with a ccpy of a Certificate of Compliance (attached) indicating that the tank was,installed within twenty,(:0) years prior to,the date of the ins yen: the septic tank whether r -_pa no t metal, is cndced structurally Il n. s ructu a unsou d shows rr: S o s subitan ial •nfil i n r mil n �} . t i trt o o e. truc , failure is imminent. The system will pass inspeZion if the existing septic tank,is'reclaced'with ?'.,rrtforrning septic mnk as approved by the Board of health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-_FOR-M . PART A CERTIFICATION (continued) . Property Addrass: ` Owner: Date of Inspection: , BI SYSTEM CONDITIONALLY PASSES Icontin x!d: Sewage backup or breakout or high static waterf level observed in the distribution box-is due to broken or obs;ruce- p1pe:si at due to a broken, settled or uneven distribution box. The system will piss inspe^.ion' if(with approval of the Board of Heaithi. Describe observations: __. broken pipes) are replaced obstruction.is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe?sl. The sys;em will pars rnsoecttan if (with approval of the Board of Health): broken pipes; are replace= obstruction. is'removed y Cl FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe• evaluation-by,the Board of Health-in order to.de:ermine 4 the systern s failing to prete^=t public health, saie:y and the environment. 1) SYM.Iv'1 WILL PASS UNLESS BOARD OF HEkLTH DETErLMINES THAT THE 15 NOT FUNCT)ONINC IN A'MA NER WHICH WILL PROTECT THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMi&T: r , Ce_s000t r i.•ti i v.•ithin t r 0 0 surface w_ p s S ee. o a su ace ate.. d Cesspoci or pin,- is ithin 50 fee: of a..bordenng vegeuted wetland or a salt marsh: Z). SYSTE.I1 WILL FAIL UNLESS THE BOARD OF HEALTH (AID PUBLIC WATER SUPPLIER, IFAPPROPRIATi'r OETER1V'INE:'TH. THE SYSTEM IS FUN CTI0ti11G'.1!N'A'MANNER THAT PROTECTS THE PUBLIC HE,,kLTH AND SAFtiY AND THE 9 ENVIRONMENT: 7ne.s;.<.tem has a septic tan) acid soil absorption system MASI and the SAS is within 100 fe tc a surf:ce4 water suppiv tributar" to a'suriace water supply. •. $` The systern has a septic cant, and soil absorption 4system and the SAS is within a Zone I of a public v.'ater sucniv we:!. The syste-n has a septic tank and soil absorption system and the • within' ` t rp y SAS is SO fee, of a private water supply we.l. The syste-n has a septic tank and soil -absorption system and the SAS'is less,this. 100 fee: but'50 feet or more from a private,water supply well,'uniess a well water,analysis for coliform bacteria and volatile organic compounds indi(=te< r the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to less than 5 ppm.' Method used to determine distance (approximation,nct.valid). 3) OTHER ' a v 3 page 2 of 10 l SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION .FORM ` PART A CERTIFICATION (continued). FI I CATI N O Propert,6 Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either -Yes- or 'No' as to each of the folioN•rng I have determined that the system violates one or more of the following failure'crttena a defined (ri 310'CMR 13.303 The oasis for this determination is identified below. The Board of Health should_be contacted'to determine what will be necessary tc correc the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS,or cesspool Discharge or'pondtng of effluent to the surface of the ground or surface waters due.to an overloaded or,clogger SA5 or cesspool. :� t 5,a:lc !leuld level in the distribjtion box above outlet inven due to an"overload(id or,clogged 5A5 or cesspool Licuid ceptn .in cesspool is less than 6" below• invert or available volume is less than 1/2 day"f!ov.. Recuired pumping more Char, 4 times in the last year NOT due to clogged or obstrucec pipes . Number o times pumped An% portion o'the So:! Absorption S.•sterr,• cesspool or prnv)• is be!ow the high groundwater etevafion Are poi' on o`a cesspool or privy (s v%ithir. 100.ieet of_a surface water supol.v or trlb,utary to a sunace,water succi% Ant potion of a cespoo' or prn-,. is %rthrr. a Zone I of a public'well.. An% pc•:io-. c:a cesspool or prn- is�,•uhin 50 feet of a private water supply well Am por;,or. o'a ce!spgol or prwy is less than 100•feet but greater than 50 feet,irom a private water suCpiv well w ;:n nc ac:eo;ab!e water Gualw, If the �%•ell'has been'analyzed to.be acceotabie, artach copy of well water ar ;' sis lei ccttiorm barena volatile organic compounds, ammonia nitrogen and nitrate nitrogen., M E7 URGE SYSTEM FAILS: 'rou must indicate e-:ne• -Yes- or `No" as to'each-of the following. The aopi;\, to large, sv<_tems.in addition to the criteria,above: The systerr serves a iacilm with a design flow, of 10,000 gpd or greater (Large:5ystem; and the ss•stem is a'sign ifidnt thre_: to public hea!th and safer and,the environment because one or,more of the following conditions exist. ° �: - Yes Na 44' the system-is within 400 feet of a surface"drinking water supply I ' the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim.Wellhead Protection A'rea`- IWPA) or a mapped Zone l! of ar public water supply well) The owner or operator of ariy such system shall bring the system andnfaciliry into full compliance with the groundwater treatment preeram requirements or 31- CN1R 3.00 and 6,00.t Please consi,lt'the local regional,'oHtce of the Department'foi-turther.iniormation." A '10 Page 3 of . - SUBSURFACE SEWAGE DISP05AL-SYSTEM INSPECTION FORM PART B . CHECKLIST Property Address: Owner: Cj yl V kC', Date of Ins pection: (� , }� r NCheck if the following have been done: You must indiczte,either'Yes or No-,as to each of the-following: yq< N0 — Pumping information•was provided by the owner,.occupant,-or Board of Health. _ None of the system components have been pumped for at least two weeks and.the'system has been,receiving'`.normaI flow rates during that period. Large'volumes:of water have not been introduced into the,system recend or as pan of this inspection. - ���`'� x — s-btj . plans have be omalned and e.amined. Note if the) are not available with �:A e V Th iac:lm or d-velling "as inspected for signs of sewage tack-up. -,t _ Tne s stem does not receive non sanitary or industrial waste now. r The site \•aC inspected e� i r signs s of brea out . . - .. _— All s\5terr, co^nponents: excluding he'Sod Aosorpuon System; have been located on the site.' — The septic tank manholes were unco%•ered. opened. and the tntedoc of the septic tank v.as inspected for'condltlor of baffies or tees. matena. o*construction. d:menstons:deptn of liquid, depth of sludge. depth of scum. . The size and location of the Soil Absorption Svstem,on the site has been determmed,based on • _ The fac.11t\ o�%ne• ,ano occupants. if dlrteren: from owneri were provided:with iniormauon`on the prope, mainte-:ance of Sub-Surface Disposal Svstem. N Existing inior-nation. Ex 'Plan.at B.0 H. _ A — L,etermined in the field t:an. of the failure,•criieria relatedr to Pan C is at-issue approximation cf distance is unacceo:abie (13.302;3i,t tl a - . - 3 IT Ir Page 4 of 30 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION "FOR.M PART C r1 SYSTEM INFORMATION' Proper 1% dress: 1 Owner. nn , Date of Ihspection: FLOW CONDITIONS' RESIDENTIAL Design fioA ¢o.d.!bedroom for S. 5 Number of becrooms--(:,; Number o`current residents r' w Garbage g•. der (yes or no,: Laundry ca.—ected to system (yes or no! Seasonal use ryes or no-: N' Water meter readings, if available (last rwo :2 vear usage tgpdt: � 1 1�- � t r6�j. �Q�•I1 �Ion,- � Sump Pump (ves or not La,: da:e c'occupar)c, - COMMERCi4L'INDL'STRIAL Type of establishment Design fio%, ¢alions/da% Grease trao present tees or no Ircus;na! 1`,aste I oidmg lank oresen: ,ves or no - n a � 2.te di scnar er• to me_.T,•, < < k ate, meter readin . rf . a '_ I i a - g a ab ;em vves or no e Las:Fa;e o; 0 :21:4711 OTHER: .:e:cribe Las, ca:e of ecc::,,anc% GENERAL INFORMATION PUMPING RE ORDS and source of rnior ;atlor.t System pumped as par, Of tnsp c:ion: Ives Or_no. � V It yes. volume pumped:, ¢allons *•: , Reason for pumping TY OF SYSTEM r Septic tankrdistribuuon'box,/sod absorption "system' ` Single cesspool _ Ovenlow cesspool Shared system (yes or no) (if yes,,attach previous inspection records, if any)" I/A Technoiogv etc. Copy of up to date contract?a r Cnner _ --- APPROXIMATE AGE'of all.Components; date installed (if known) and source of information tvh t.0 U�,u,Q Sewage odors detectej -hen arriving at the site. tees or nol, ` g page 5 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . c SYSTEM INFORMATION (continued) Property Address: Owner: S, \U l� A Date of Inspection: 1 t BUILDING SEWER: (locate on site plant Depth below grade. Material of construction. _cast iron _ 40 PVC- other (explain' Distance from private.,water supply well or suction Ire Diameter Comments: (condition of joints, venting, evidence of leakage. etc.( SEPTIC TANK �-S' tlocate or site pfan Depth beloA grade ;` l Mater,al o: construction concre;e._me:a _Fioerglass _PoIvethylene othenexplain { It tank is me-.al, lis: aee _ I; age conf,rmec o% Ce.^.ftca:e of Compttance Dimensions 1 u oo�f•' Sludge deoth a u Disiance from too e: siucee to bonorn of oufie`. tee o, ba';e Scum thickness 1 t Distance from top c: scum to top 0. outlet tee or ba`a _ M Distance iro-n bonem o. scum to bo-e o;outlet tee r bz-e F-o\,% dimensions %ere determines Comments trecommendation icr pumping, rondition.0' inlet and outlet tees or baffles, depth of liquid level in reiauon to outlet invert.structural ategri evidence of leakaee. e:c.r GREASE TRAP:�� (locate on site plan: r Depth below grade r Material of construction: _concrete metal Fiberglass Polyethylene —other(explain) - Dimensions: _ Scum thickness: - Distance from top of scum totop of outlet tee or baffle.- Distance Distance from bottom of scum to bottom of outlet*tee or baffle:-' x.. Date of last pumping: Comments: , tre:OmmendaUpn for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation-to outlet invert,structural •--- ;ntegrtc', evidence of leakage. etc.; Page 6 of 10 ' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.M PART'C c, SYSTEM INFORMATIO0! (continuedl: Propert, Address: �4Q - Ow ne r, . J �- Date of Inspection: "I k TIGHT OR HOLDItiG TANK: 1"V lank must be pumped prior to, or at time, of inspencini (locate on site plan. Depth below grade material of construction _concrete _metal Fiberglass _Polyethylene _other(explain)_ Dimensions: Capacir'• gallons , Desly f101 galtor's da> Alarm level Alarm ,n %%orking orde• Yes, No Date of previous pu.nping (conduion of mle; tee. condition o- a!a-m and floc: s�-%•ttches.`etc.l' DISTRIBUTIO'1� BOX— tiocz:e on site p a- i De.:', o� Iicuid tee' a00%e oune: on%e.. mo:e :f le e! a-,d d!s,,•ib-:nor 11 el a' evic.ence of solids 6ri-over, jence of leaka a into gr gut or boa, etc.I PUMP CHAMBER: (locate on site plan. PumrS in working order: (Yes or No' Alarms in working order (les or No Comments: (note condition of pump chamber, condition of pumps'and,appurtenances, ete.)' `9 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit PA RT C t a SYSTEM INFORMATION (continued) Property Address: (ZA Iz (\)�nn,O r1 E. t 4b Owner S�\id(e., 1 Date of Inspection: N" y? SOIL ABSORPTION SYSTEM (SAS): S (locate on size_plan, if possible; exca%anon not required, but may be approximated by non-intrusive methods;. If not determined to be present, explain: Type leaching pus. number. kto �. leaching chambers, number: leaching galleries. number: t a leaching trenches. number,length: - leaching melds. number, ci,-nension; overiio cesspool, number Alternative system , Name of Tecnnotogs a Comments a in to condo n of$oil. sigr.s of hydraulic failore.'Ievei of ponding. condition of vegetation, et �.. 1 l iF _-. L1 o m• CESSPOOLS; (locate on site play. ` humbe, and coni,g..ra:,o- - Depth-too of liquid to inlet Inver, Deoth of solids lave Depth of scum laser Dimensions of cesspoo: - - - - - mate,tals of constructor T' Indication of grounclwate inflo,+ (cesspool must De um p• pe., ai par,.of inspection, Comments: x' ' (note condition of soil, signs'of hydraulic failure, lev'el'o-f ponding, condition of vegetation, etc.) s PRIVY: (locate on site plan) Materials of construction: . Dimensions: ' • , Depth of solids: Comments (note condition of soil, sign' of hydraulic failure, level of pondmg, condition of vegetation, etc:) Page a of 10, SUBSURFACE SEWAGE DISPOSAL SYSTEM-IN SPECTIONJORM(r. J; PART.C' SYSTEM INFORMATION (continued c��.► , Prcpem Address: Z F ; Owner. Stvlw Date of In,pection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house! it 41 r � �.o. • .,t to , gym, . SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM_. PART C _ .. SYSTEM INFORMATION (continued)' Propem Addre•s° e Date of IInspe!on '� r n 'w Z t, ou De to G a ate• Feet , 0 ee Please indicate all the methods used to determine High Groundwater Elevation:. a Obtaine-d' iron Design Plans on record Observation of Site (Abuning.property, observation hole, basemeni'sump e:c.). Determine it irom local conditions, Cnec dn loca' EGard 0' Chec, F;MA Mac: � C�e,l pump n€ record Chec+ loco' rrs:alle•s r Ce�c-'Ce o.•- .orc: ro.• %o_ es:ac;ahec t e. g6-'Cround),%a!e•,n.Eie.ation tMust,be.co „e,tec � N �S � w ��.( �� L�►VW`p. �Z� �-� �v ill - M -w 1:w_,..a• :�..'' 9"' - ll►q• 30 oL .10 .. .. TOWN OF BARNSTABLE 4 � i14. LiCt'►...:ON o-.� � � � SEWAGE# VILLAGE �a * vll�y, 1 ASSESSOR'S MAP& LOT OLA 0V,60b INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY q�'1 LEACHLNG FACILITY: (type) ( - (size) NO.OF BEDROOMS p BUILDER OR OWNER PEDATE: �ti� �/� _COMPLIANCE DATE: f Separation Distance Between the: l Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist (PA . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist wb �., within 300 feet of leaching facility) - 1_ Feet Furnished by rLI ( a, `Y 3 to Q ig�- TOWN OF BARNSTABLE LOCATION Ale, SEWAGE VILLAGE L U ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. U��dl�' 1312�S a� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER MAC/q : PERMIT'DATE: I I COMPLIANCE DATE: -- h _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ ._ „ , t, 4 �- Y y ` , , �; ��s� .. .� � /oS/� � ` � _/ 4j .. yj - ���� 3 (2 �� � a � TOWN OF BARNST ABLE e � LO 12 1 Lo ;r* 4 SEWAGE VILLAGE ASSESSOR'S ASSESSOR'S MAP & LOT „y-(UL� INSTALLER'S NAME PHONE NO. V N C1�— ':zx::--f { SEPTIC TANK CAPACITY 1000 LEACaING FACILITY:(t7pe) (size) EQ �'��` p i� NO. OF BEDROOMS PRIVATE WELL.OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: D1 TE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes. No Lo+ . ram , FRZ THE COMMONWEALTH OF MASSACHUSETTS D�J OARD OF HEALTH �'R� '' ... OF... . I O . ._ d. ,. Applira ion for Dispusttl Works n Permit Application is hereby made for a Permit to Construc ) or Repair ( ) an Individual Sewage Disposal system... L'-p .. -- =- . . . G;� . . . --•..... .. ...............�................... ....•...... ................. ocatiot o Lot N . -- .. Own ..._ ..... «... Address W `S ...: Installer Address L�(� Type of Building Size Lot.. 15............Sq. feet U ' .. Dwelling—No. of Bedrooms...............15---------------.-------Expansion Attic ( ) arbage Grinder.( ) Other—T e of Building a YP g •--------.................. No. of persons............................ Showers ( ) — Cafeteria ( ) - dOther fixtures .--•.....--•---........_•---...... _..,.._.._:... Design Flow...........- •- - ............:. .gallons per $er day. il flow..._._....--.-- W Y Y �i'�--a................ .....Ions. WSeptic Tank-Liquid capacity.. gallons LengthV..`ij.�... Width:��,(.'( : Diameter................ Depth: ..... x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..... .............. Diameter.......10........ Depth below inlet........�j.......: Total leaching ar ...sq.,ft. Z Other Distribution box s:� Dosing tankPercolation Test ResultPerformed by.. WDate�€K1••� ..... X '-... .... .. ..�.tt... ......... ,.a Test Pit No. 1._..._._.. inutes per inch Depth of Test Pit........ . t�. Depth to ground w ter... ...(.1 f� Test Pit No. 2.................minutes per inch Depth of Test Pit....... ... Depth to ground ater:....................... a �t..__... �1....:....... ::. ... ......... 4.�1........... O Description of Soil....... „- _ - .. - :. ......_ ��.0 .... ------------------------------------•----------------------------...-----------------------:....---------------------------•--•------------•-------...--------------------...•... ......... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...--•--.......-•--•-•---_--••--••--•..............•------•-•---.....---....-•---••-----••---...............-•---•--------•-----------•---...:--•-••-----....--•---•-•--......................:.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:ITLZ 5 of t tate Sanitary Code— The undersigned further agrees not to place the"system in operation ntil Certificate of pliance has been issue t e board of li th. Signed.....t!- .:./ � ' .. X... ............. .... Applica 'on Approved By......... �� �t...� 1 �. ..........Z. .......... =. Date Application Disapproved for the following reasons:--= _..::._..................... ...«« N � ;.. ...................... f - Date o... IPermitN -. ..- - .........«..._.. ....« O( Date THE COMMONWEALTH OF MASSACHUSETTS yo BOARD OF HEALTH 4 ...! ...v` ^✓.............OF.....(:_- .. :..:!r`....-v..�..A- I............................... Appl ration for Disposal Works Tonstrur#ion 1rrmi# Application is hereby made for a Permit to Constrl (�) or Repair ( ) an Individual Sewage Disposal system at��� � G• �� � _ V . •Location-,Address of Lot Nt. �2 ......, - ... _ - ----- --... . .... ........:..... Address ..... ....... ......_............_............. ..............-----.._..._._..........._.....:..._..........X...................... ........... m Installer Address -7 Q7i Type of Building Size Lot._._........`�....f.J....J....Sq. feet U Dwelling—No. of Bedrooms................... .......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures .....................`.. w� .......-- WDesign Flow............1.1_ _. ...............:..gallons per.person per day. Total daily flow.....................................:.....gallons. W Septic Tank—Liquid capacity.J ]lops Len Yt)_6,i��... Width- A:-._. .Diameter._._._ r� •--•ga � .:� �- "l r {/.. ------ Depth,.: x Disposal Trench—No..................... Width............... Total Len Total l'eachi g' ` -'' x'° rF q.f p ._... gth....-•--...------• �area....................s ft. 3 Seepage Pit No......c.............. Diameter.....��..._..... Depth below inlet......... Total leaching area!1,1 i�.-.sq, ft. Z Other Distribution box ( ) Dosing tank ( ) ''" Percolation Test Results Performed by...... �l /1F`f - f�i lam: II'P�. Date.__...._ �._... a .�....V r^; ....Y ` ._...__.r... Test Pit No. 1._.._._._.. -minutes per inch Depth of Test Pit..._ _��-�!...__ Depth to ground water...:?a.�.:'r. 44 Test Pit No. 2................minutes per inch Depth. of Test Pit........... .... Depth to ground water........................ O Description of Soil .....� -------�,©(`� �' e J �/ G. ._._.. �� �O SfIc_ = t �w p .......................,_................; ........_._._._ _ �--yr......................................................... WV ...................................•------.--..-•-------•---•-------------------------------•----------.---------------------.-•,��_�_._--r'-."••E'---:... ,f�/U('� 12F�(�F ( :; x ........................•--...........--•--•--.............._.........--------•---•-----................-------------•--------:.....----.......---.....-----.....-•-------------------•-••----••••-•.... U Nature of Repairs or Alterations—Answer when,applicable._...._......................................................................................... ......................................................•-------------•----•--•----•-.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLW 5 of the4tate Sanitary Code— The undersigned further agrees not to place the system in operation until a.Certificate of Compliance has been issue the board of health. A Signed ...�..-- ..l. r ��..�..�. ..... -,� 1� 1� .. .... APPlicatton Approved By.. .-� .� ✓!//t �- - • -.--...... ........................... ........................................ Date Application Disapproved for the following reasons:...................................................... ................................................. ..............•-•---•--..............----•--••------•----------.............................-..--.--............---------•--•-•---...----..._.--•---....----................................--••........ Date Permit No.. �... J , -----.. Issued. .................................................... i / ....2 7 o Ca Date ---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ter#if iratr of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V/ or Repaired ( ) by.........1 ......1./f•�.. .... ��. ... -- . ..........-•---•---•----••-•--•----------- ................•-•--.......................... Installer 'ry ...... .. _�a ...................................................................................at D ...__. ... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit iv o.C -:��?...... 1__CC?_^?-__. "dated..... ..�?�. 'd! THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 41 DATE.............•••.... L•' fl.............._.._.......... Inspector.............. ............... i. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �f1{,2111 ......OF........../✓. ✓. ,'i ;3 i;t No �...��•(n 2 :............... Fn......... Disposal Works (fono#rWion Prrmit Permission is hereby granted......•---�7 -• ....•...:' ..:................ ._.. to Construct ( or Repair ( ) an Individual Sewage Disposal System at No.....�(,?.1....1o......�yAele 6 ..r�,......!.Aj•v� _......_ )r`�/ 7i/r3Lt�.................... • .............. --_..... Street --as shown on the application for Disposal Works Construction Permit Now.....,.1..:?.Date d.._....�----.,--.-� .................. /� 1 = - .............................. p �/ �Q ! �� /1.................. Board of Health DATE.....y..----•----•....................�-•-----�-T- U0- yo Y 125 G:. .... ... -35-00 _- � Cam' _r �' •- . ._ - �i a •'" 9 I JOB # 85-516 CERTIFIED ;kP. L-_DT PLAN ' PREPARED FOR.- . LOCATION: CRANBERRY rLN . BARNSTABLE; SCALE: 114=30 DATE. 10/17/88 REFERENCE r ASSESS Mal', 234 PCL 66-6_ 3AYSID;E BULLRING t _ • _ t ., ..'.' -- - ' .., a _ ..,•F L, I HEREBY CERTIFY THAT THE BUILDING SHOWN ON .THIS PLAN;ISM LOCATED`ON THE' F a GROUND AS°SHOWN HEREON. 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DATE DESCRIPTION NOT TO SCALE P 12688 NOT TO SCALE NOT TO SCALE NOT TO SCALE 5" DIA. KNOCKOUT (TYP.) 1. 9/18/12 REMOVE NOTE REMOVABLE » NOTES: #2 2" WALLS COVER 3 1. ONE ACCESS COVER PER TEST PIT #1 TEST PIT S' RAISE EXISTING COVERS C10 m o E7 0 O C] E7 E7 SYSTEM SHALL BE RAISED GRD. EL. 64.6 GRD. EL. 64.3 1. INLET AND OUTLET TEES SHALL BE INSTALLED TO WITHIN 6" OF FINISHED TO FINISH GRADE. 54.19 53.89 IN EXISTING TANK GRADE USING SEWER SHGW EL. SHGW EL. NOTES BRICK AND MORTAR AS 9_1/2" C7O OCI L�L�C7 C7CD C7C7 2. CHAMBERS SHALL BE GENERAL NOTES: 2. TEES SHALL BE SCHEDULE 40 PVC AND SHALL NECESSARY 500 GALLON LEACHING 1. NO GROUNDWATER BE LOCATED WITHIN 12 INCHES OF TANK WALL 6" MAX 0 0 NOTES: DRYWELL, MANUFACTURED BY SANDYpLOAM SANDYpLOAM OBSERVED 11-1/2" Q� m 0 0 M� M O MCI SHOREY OR APPROVED EQUAL 1. THIS PLAN IN ONLY INTENDED FOR THE 10YR LOAM 10YR 2O y 1. DIST. BOX TO WITHSTAND H-10 LOADING DESIGN AND CONSTRUCTION OF THE 8» 9" 2. NO REDOXIMORPWIC o / UNLESS UNDER PAVEMENT, DRIVES OR SEWAGE DISPOSAL FACILITY. FEATURES OBSERVED TRAVELED WAYS WHEREIN H-20 LOADING I 8'-6" I Bw Bw 2" ` BOTTOM ON LEVEL SHALL APPLY. `-� 2. ALL CONSTRUCTION METHODS AND SANDY LOAM SANDY LOAM ;. •• •a .• STABLE BASE MATERIALS SHALL CONFORM TO 310 CMR 10YR 5/8 10YR 5/8 6" MINIMUM 2. PROVIDE INLET TEE OR BAFFLE WHERE 15.000 AND YARMOUIH BOARD OF 3/4" TO 1-1/2" SLOPE OF PIPE EXCEEDS 0.08 FT./FT OR LOAM & SEED DISTURBED AREAS HEALTH REGULATIONS. 26" 26" PRECAST SEPTIC TANK 10" _ SECTION VIEW CRUSHED STONE IN PUMPED SYSTEM. 3. THERE ARE NO KNOWN OR PROPOSED COMPACTED FILL (12"-36") " p PRIVATE WELLS LOCATED WITHIN 150 FT. EL 62.43 EL 62.13 3. FIRST TWO FEET OF PIPE OUT Of DIST. 2 LAYER OF 1/8 TO - BOX TO BE LAID LEVEL �_"• 0 { 1/2" DOUBLE WASHED OF THE PROPOSED LEACHING FACILITY. STONE ABOVE CROWN 4. IF AN OVERDIG IS SPECIFIED, REMOVE ALL F T4. ALL PIPE CONNECTIONS AND CONCRETE �� M 0 0 � 0 OF PIPE * C C - LOCATE a " CONSTRUCTION SHALL BE WATERTIGHT. 34" 24" / TOPSOIL, SUBSOIL AND OTHER COARSE SAND W/ COARSE SAND W/ 60 INLET TEE (5) 5 DIA. 0 C7 C7 C� UNSUITABLE MATERIALS. GRAVEL & COBBLES GRAVEL & COBBLES UNDER COVER 900ELBOWUTLET ON 13" I KNOCKOUTS I 5. FILL ALL UNUSED KNOCKOUTS WITH MORTAR. EFFECTIVE 3/4" TO 1-1/2" 2.5Y 6/3 2.5Y 6/3 TYP. DEPTH / 0 0 DOUBLE WASHED 5. If AN OVERDIG I5 SPECIFIED, REPLACE I 0 � O L� C1 STONE TO CROWN ALL EXCAVATED MATERIALS WITHIN THE L • =7 OF PIPE LIMIT OF EXCAVATION WITH CLEAN PLAN VI 4'-10" GRANULAR SAND, FREE FROM ORGANIC * GEOTEXTILE FABRIC MATERIAL AND DELETRIOUS SUBSTANCES. EL 54.19 EL. 53.89 " CROSS-SECTION VIEW 21" ----"-) 12'-10" MAY BE USED IN LIEU OF MIXTURES AND LAYERS OF DIFFERENT 125 125 DOUBLE WASHED STONE _ _ PAN SEW CROSS-SECTION CLASSES OF SOIL SHALL NOT BE USED. FILL SHALL NOT CONTAIN ANY MATERIAL ESTIMATED \ �1 LARGER THAN 2 INCHES. A SIEVE �-- SEASONAL HIGH 1 .�s of DESIGN CALCULATIONS. ANALYSIS USING A #4 SIEVE SHALL BE GROUNDWATER \E�`rRIC -� '"---�'�- PERFORMED ON A REPRESENTATIVE �; SEPTEMBER 17, 2009 \SaMpA EXISTING FLOOR PLAN_ y NOT TO SCALE SAMPLE OF FILL. UP TO 45% BY WEIGHT TEST BY: BSC GROUP, INC. GROUNDWATER v OBSERVED `N''�as£M`NT MAY BE RETAINED ON THE #4 SIEVE. OPEN SIDIA-ACE ``- DESIGN FLOW: SUCH ANALYSES MUST DEMONSTRATE WITNESSED BY: DONALD DESMARAIS, R.S. \ THAT THE MATERIAL MEETS EACH OF THE PERCOLATON \ FOLLOWING SPECIFICATIONS: STORAGE 3 BEDROOMS ® 110 GPD BDRM = 330 GPD PERC. RATE: < 2 MIN./INCH TEST RANGE \ WALKOUT 10OX MUST PASS #4 SIEVE .�� -- - SOIL .EVALUATOR: BRIAN YERGATIAN, P.E. \ 1OX MUST PASS #50 SIEVE UNSUITABLE \ DECK REQUIRED SEPTIC TANK: 0-20X MUST PASS #100 SIEVE SOIL CLASS: CLASS I MATERIALS \ FAMILYROOM FINISHED / OPEN AREA 0-5% MUST PASS #200 SIEVE LIMIT OF OVERDIG AND ` 330 GALLONS X 200% LT A•R.: 0.74 GPD/S.F. (TO BE REMOVED) REMOVAL OF UNSUITABLE •.,� = 660 GALLONS 6. EXISTING UTILITIES WHERE SHOWN ON THE [BATH SEPTIC TANK PROVIDED = 1,000 GALLONS PLANS ARE APPROXIMATE. THE ENGINEER N84'03'S0"V MATERIALS \. - -- DOES NOT GUARANTEE THEIR ACCURACY 125.00 \ 1� I DINING KITCHEN BATH aaOM LAUNDRY OR THAT ALL SUBSURFACE STRUCTURES \ `\ GARAGE I SIZE OF LEACHING FACILITY REQUIRED: ARE SHOWN. CONTRACTOR SHALL VERIFY LOT5 / I THE SIZE, LOCATION AND ELEVATION OF DATUMLOT1622.8' d EDGE OF I BASEMENT FLOOR DESIGN PERC. RATE: <2 MIN/INCH INVERTS OF UTILITIES AND STRUCTURES, 2122 # S.F. ,/' ,� STONE LIVINGROOM OFFICE -- - WITHIN THE LIMIT OF WORK, PRIOR TO THE 5 I � BATH BATH LONG TERM APPL. RATE: 0.74 GPD/S.F. START OF CONSTRUCTION. IF ANY VERTICAL DATUM: ASSUMED 17,563t S.F. /36.6' I BED #2 330 GPD = 0.74 GPD/SF = 446 S.F. DISCREPANCIES ARE DISCOVERED OR FIELD i CHANGES REQUIRED, THE CONTRACTOR 7FIRST FLOOR BED #i i BED #3 SHALL NOTIFY THE ENGINEER IMMEDIATELY. BENCH MARK SET: 1. HYDRANT TAG BOLT, ELEVATION 68.64t MSL OBSERVATION _ LOT SIZE OF LEACHING FACILITY PROVIDED: 7. THE CONTRACTOR SHALL BE RESPONSIBLE 2. TOP OF FOUNDATION, ELEVATION 69.30f MSL '� �` , PORT �� OPEN FOR PROPERLY COORDINATING THE a, #128 EXISTING 3 BEDROOM DWELLING USE (3) 500 GALLON CONCRETE CHAMBERS PROPOSED CONSTRUCTION ACTIVITIES WITH Y„ D-BO N I� INTERIOR PLANS ON FILE AT THE BOH DIG-SAFE AND THE APPLICABLE UTILITY i CLEANOUT SECOND FLOOR SIDEWALL AREA = 2(33.5 -I- 12.83 )(2) = 185 S.F. COMPANIES, AND SHALL COMPLETE THE 6 i BOTTOM AREA = 33.5 X 12.83 = 429 S.F. -�-- N TP-1� I PROPOSED WORK WITHOUT ANY SYSTEM PROFILE -� N I � 614 S.F. INTERUPTIONS IN SERVICE. o \ 1 �w 614 S.F. X 0.74 GPD/S.F. = 454 GPD 8. CONTRACTOR IS REQUIRED TO NOTIFY NOT TO SCALE PROPOSED w DIG-SAFE, PER MASS. STATUTE CHAPTER /�o� PROMOSEDD `� TIMBER RETAINING WALL ��WER LINE CLE/`1N 0U T MINIMUM OF 72 HOURS PRIOR TO THE 82, SECTION 40 (1-888-344-7233) A \ (3) 500 GAL. TOP OF WALL EL 64.00 S Lam, CGkC. LEACHING -"-24 7. SCALE:`NONE AM HBER5 `, START OF CONSTRUCTION. EL=A FIRST PIPE LENGTH moo. \® 67` �. ® 'p' 9. THIS SYSTEM IS NOT DESIGNED FOR THE TOP FOUNDATION TO BE SET LEVEL ' J CAST IRON MANHOLE NEENAW CONCRETE COVERS TO WITHIN FOR MIN. 2' `� $ OR EQUIVALENT FOR 4" PVC PIPE USE OF A GARBAGE GRINDER. EL=67.Ot p INSTALLATION OR USE OF A GARBAGE 6 OF FINISHED GRADE .i FINISH GRADE � � �+ co FINISH GRADE GRINDER AT THIS PROPERTY IS NOT 4" PVC SCH 40 E 3.5- 'S 0 ALLOWED PER 310 CMR 15.2404 . ® 1.7X DECK w r^�711 ,,,;': A ( ) 4" PVCC U so 24" SQUARE CONCRETE COLLAR SCH 40 4" PVC SCH 40 LEACHING CHAMBER c © N (3,000 PSI) ALL AROUND L 0 C U S I N FO R M A TI O N 121 ® 7I=E #128 EXISTING w ooe� eMcmoc� rMoo =B I=D I=G c� o 0 0 0 0 0 0 o a EXISTING \ 3 BEDROOM 1,000 GALLON ZA \ DWELLING 4 ¢ BSC GROUP I I=F H SEPTIC TANK GARAGE \ 4" PVC PIPE CURRENT OWNER: RICHARD NEISIUS 5 OUTLET I(OUT)=63.76 \ iE • SEPTIC TANK DIST. Box 5.08' SEPARATION \ 0 a. 4 45' BEND TITLE REFERENCE: DEED BOOK 11525, 199 349 Route 28, Unit D CLEANOUT px4 px4 p Y BRANCH W. Yarmouth, Massachusetts EST. HIGH GROUNDWATER DECK ` PLAN REFERENCE: BOOK 426, PAGE 8 02673 �\ ) LP 4" PVC PIPE ASSESSORS MAP: 234 508 778 8919 F 1a1 / EXISTING PARCEL: 066006 © 2009 BSC Group, Inc. l 1,000 GALLON S (2) 45' BEND SEPTIC TANK m WATER SERVICE CROSSING ZONING DISTRICT: RF-1 SCHEDULE 0 F ELEVATIONS c ► I(OUT)=65.30 / SLEEVE PROPOSED 4" PVC #130 EXISTING � .�..-6 �` WITH 8" D.I. PIPE SETBACKS: FRONT 30' PROJECT TITLE::. . 3 BEDROOM � �"" .� �� N �\ SIDE 15' DWELLING - •,� REAR 15' DESIGN FOR TOP OF FOUNDATION 69.30 A EXISTING �.� � �� s 28• � \ MINIMUM LOT SIZE: 43,560 S.F. (EXISTING) S m SEWAGE DISPOSAL 4" INVERT AT BUILDING UNKINOWN `� \F �� CUT AND CAP EXISTING TOTAL LOT AREA: 17,563t S.F. �8) � ....., \ EXISTING PIPE 4" INVERT AT SEPTIC TANK (IN) 65.55 C °� ;? �" � \ NITROGEN SENSITIVE SYSTEM REPAIR (EXISTING) GARAGE `� \ ZONE: ZONE II 4" INVERT AT SEPTIC TANK (OUT) 65.30 D (EXISTING) Zy �� �� F L� 5• p' FEMA FLOOD 4" INVERT AT DIST. BOX (IN) 61 .64 E �` c R- \' ZONE DISTRICT: "C" DATED 8/19/85 #128 250001 0005 C 4" INVERT AT DIST. BOX (OUT) 61.47 F _ 6J 6 PLAN NOTE OVERLAY DISTRICT: GP CRANBERRY LANE INVERTS AT LEACHING FACILITY: 7"\1 LOCATION AND SIZE OF EXISTING SEPTIC SYSTEM COMPONENTS WAS OBTAINED FROM RECORD PLANS LOCUS MAP CEN TER V I LLE 4" INV. AT LEACHING CHAMBER 61.27 G (BREAKOUT 61.7?) ON FILE AT THE BARNSTABLE HEALTH DIVISION. NOT TO SCALE MASSACHUSETTS ELEVATION AT BOTTOM OF CHAMBER 59.27 H � `` °a BENCHMARK HYDRANT TAG BOLT #292 SEASONAL HIGH GROUNDWATER 54.19 J EL 68.64t MSL . N 60 ! w,� LOCUS PREPARED FOR: OPEN SPAO 132 .- �� ' � BLUEWATER HLD I 350 ROUTE 28 J � � 6 A N WEST YARMOUTH MA 02673 VARIANCES REQUESTED � iB �. Q ED 1 �` R �`'OF 508 775-2800 NONE NbnB y 50,wide � oR e � q N � � e I,&_9FMgs CRMOA. w FOUND BOUND rCq,, DATE: SEPTEMBER 23, 2009 ;sgCy � FOUNDD && HELD COMP. DESIGN: B. YERGATIAN ygWMTIAN , G.E CONCRETE BOUND �, CHECK: K. HEALY w I IL„ � �- FOUND & HELD � A9 9�� °°� tlle PLAN VIEW �---_ G�� DRAWN: P. HAGIST �� SCALE: 1• 20 FEE CONCRETE BOUND e ,ZJ FIELD: P. HAGIST TION - T FOUND & HELD - - - FILE NO. 4944500-SEP.DWG DWG NO. 5968-01 0 10 20 40 FT, JOB NO. 4-9445.00 SHEET 1 OF 1 NX, NO- p- ul"'W"N'.11 �ax W , "" o m Nar MQ sw Kill Mt lZit al I,- art I 'g i� -.TTI�I VMS!, INNA k�'w lot WIN, OW,-- io AN41, J "Aft MY OKI Sol rw a, ,1-5 I PY 't "PIN pill Flu, 41— WA M,IiV� A� 91 51 V.x 111�j Ko 000 kNlza ac,""', Ww 4 -®r 64 G 3 TOWN OF BARNSTABLE LOCATION �� �1 �� SEWAGE # N VILLAGE �� '� ASSESSOR'S MAP& LOTA9186M INSTALLER'S NAME&PHONE NO. I�! SEPTIC TANK CAPACITY r LEACHING FACILITY: (type) (size) I t JV NO.OF BEDROOMS BUILDER OR OWNER Puaaf b. ATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / Feet Private Water Supply Well and Teaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility).. , Feet Furnished by f�'� 13 ` a� i CONINIONV-E.-UTH OF M4SS.;CHL'SETTS ExECItIVE OFFICE OF E?�ti'1n0\tic\Te.L AFFAIRS 4 r DEPARTMENT OF ENVIRONMENTAL v PROTE 1� l gt� »' OBE WINTER STREET. BOSTO�. N:.� C-2106 el'•.s:•��( Ifs •. • , • �� q ��e► MLLl.01 F UILD ro 4 0 I�.1)1 CC is Govr..c' ' . i tiOo f Sc:-; is : .•. . . . .. _ r �� /vZGEO PALL CELLL'CCI � °Eq�go �� D��'1D B Sin; �- L:.Gavc^or SLBSUR.FACE SF5'VAGE DISPOSAL SYSTFM,INS?ECTIO �Ffl' tit mot`` Co--.iif ss„ PART A ' 4 CERTIFICATION Prcper'y Addres,; Zy - Nbec1L� �tq-"'t�• Ad •re-ss of Owner:' Date of Inspection: I$ ��� /' 0&0 Z Of d:Hvent; Name of Inspector: Hie A a'O }' ► 1 E�ECG` 1 am a DEP a ro\e. systeM inspector pursuant to Section 13.3=0 cf Title S (310 C.MR 13.000) Company Name:J^47-' y-r'r--.. .0 Mailing Address: "pQ �e� r 3�p C1 Telephone Numbv: r5e2`2 4 Q CERTIFICATION STATEMENT I ce':� tha: I have p!•SCna!l\ ,rst?ec-er 0 a selvage d-s:Ls:! s\•Ne-n :: this :C:'e!! and l':: 116,e IntCr-a:,cn re:crPd be•c- IS :r.d czrncive a; o•.the time Cr ,n!;ec: Tne Ins:et.C' Ma! pt'. e:'t1!K Cn e.\ tr::r.irt VC. ex-vnenc! in the ptc:%e' tunc:xn a-: rn:,ntenance c�on-we selvage d,s,:cs: t\'ster..! Tne s\s:e-n:: Fa!;e! cnc•t,c a,:\ False: ; Furne E•�a'u:;;c E% me Lcc.;l !.;�.;cvin.€ A_.n cr: Fa. • 7 In5Pe':!0r•s Sit'Sa'Ure. Insr,Cc s : S-t"',: a.cC:, C- tn.s ins:?C•cn re:ci IC 'e A.: _ :ng A ^.Cr.., C:.s [' [_-,tie:!rc t7o ins:?'_:,c. I: me wtvn ,s : shoe: !\ste- e• hap a ee! fn f!cM c: 1C.000 gx Cr g e_:e . I-e ,r.s:e: r anc me s\s:e-.. c -r.e the re__- tc .ne a:_ cr:::e revcra'e=.ce c the C•e: --.e^t C. -.,rc'nr-e- o Fr .e Tne cn¢ ^:' s cu:d to s2 tc I^e s•s:e- c� :.-•t: cc .es .- tc the bu\e•. ii npflca-ie. and me INS?E010♦ SLIMmARY. Check A' 8.. C' oir D A, SYS T E.M PASSES: I have nC fEu• IntriC7(es It-;: the s'j5 e - YiC o e! nY Cf I`e <•i t �t 6 e .. _ C Ctit.i 1 Any ta,iure c.:leriZ nQ: eva!uaieC are lr,d,c,e: be'oM COMNAENT5 T B; SYSTEM CONDITIONALLY PASSES: One c' ncre system components'as describer? in the 'Ccr.ditioha! Pus se icn ne•-•_' It: be replace,-' . Th �. o•' r �. rrd a \s•s,e'n, u c-'m„!etien of the replace^5ent or repair, as a*proved by the Bear-' of Health, will puss. r Ird,ca:e YC!. ric. o• ne: dver�nlned (Y. N. or NO,. Describe basis cf dote.^in:: en in all instances. If 'net dete.^_irr_'-; ezr!airi w-h nct. — .• Tne seet,c tank is metal, unless the o-ne-or ope.-atcr his provide- the system ,r,speccr with a rry of a Ce^.ifnte of • C-^mPl,ance tacachedt indicating that the tank wu insulle•-' within r en'y ('CI years prier to the date Of the insxaio^• ' the septic uni. v.he;her Or net rne:a!, is cracke-', s;rucurally unsound, shows subs artia! infiltraier Or ex!'iItmocn, or ur (;,lure is ir.:m,nent. The sys:em will pus inspe:'icn if the vusnr.g septic tan& is re^laced with a c=r5for1Mng srptie tusk , A! 2;orovecl by the 6car� 01 health: R r F ' 5USSURFACE SEA,ACE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continue i Property Adduss: O%ner: Date of Inspection: . 'B1 SYSTE.•t CONDITIONALLY PASSES (contrn,;�: I - Se%age backup or brealout o' hi'sh ra;c water leve! cbser,e-_' in the disenbuticn box is due to broken or cbs;ruce" pipe:sl or due to a broken, senler or uneven diS;ributicn bCz. The system will pass inspet ion if(w'`7 approval of the Beard of Health). Describe observations: broken r P pe s) are rtplacr' - obstruc;icn is remove! distribution box is levelled or re;,laced ' The system require- purnping more tr.:n`fcur tires a year due to brckr, cr cistruc:ea pipes). The sys;ern'will pars I1150'ec110n ii (W'ith a;proval cf the Board of Health) broken pipes; are reaace^ , obstrueicn a remcve. Cj FURTHER 5'ALL'ATION IS REQUIRED BY THE BOARD OF HEALTH: CCnd1UCnS exist which rt';virt lur h't' evalu:IiCn by tf BC:rd Cf Heal,- ut c,.ze! to cete—nin! if the s)Ste'tt is failing t0 rct _. i B P e^ t t F public heath. s:ie�'and the envirchme^t. t 11 SYSTEM FILL PASS LINLESS BOARD OF HEALTH DEFM"I\ES THAT THE SYSiEm IS N07 FUt1CTIONI.%,,G IN A MA\NER I WHICH WILL PROTECT THE PUBLIC HEALTH AtiD-SAF--. A."D TH: ENVIRONME%T: i _ Cemccel cr prig-, iS Within 50 ie': ci a sur:ce wa•e- _ C!'_SCCCl o: iS W i ^,ir, jv ie'-: ci : t:Crde•u g ve$tt;-.e-21 weLI11G� or a S;II ranh. SYSTEM WILL FAIL UNLESS THE BOARD"OF HEALTH, fAND PUBLIC WAItR SUPPLIER, IF APPROPRIAT • DETERMINE: TH,, I THE SYS7E.1-i'15 FU^CTIONONC IN A MA.NNIR THAT PRO TEM THE PUBLIC HEkLTH AND SAFt�i ' AND THE ENVIRONMENT: _ The s,,•:;em has a se, ic'tzni and sci; :CSc:r,':c:S sys;em tAS, and the SAS is within 106 fe-:'tc 1 sue.'ice water sup.iy c tritutary to a sur,•:ce rare suC�i•. , Tr.e sysce r has a S2:UC.(:n� and Sc l :CSC:,,:;cn syS;e!n and the SAS IS within"a ZCne I of a pubic Water sup-iiv wet;. The sys;t-1 has a sepl c t:n; andSJii :.SC:;::cn SvVe.n 2:i Ile SAS is wit..^.in SJ fr_t Ci 1 r;�':;t Witt.' U 1 Wt'; 4 _ C s CC y _ The systems has a seaSic ta-.: :-C sc i a:sc:;;:cn sys:e n and the SAS is less than 100 fe-: but 50 fr.! or more from a j private %ate' succly well, unless a well w::e' anaysis fc.' c_iiicrm baceria and volatile Organic C:•"r+Curds indiGte- l� the well is frea fro-- pollution frcr„ L;: f;c;hrf and the prrx�:- of ammeniz nitrogen ar,d ni;;.te nitrogen is e,�;:! tc c less than 5 ppra. Me:ho uw-"to de:e•.-ine dis:n c_• (approz;r..ation not valid). 3) _ OTHER s a . - fit - , _ ♦'� i ' 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTIO-N FOR.%i PART B CHECKLIST N , t< Property Address: kZC1 CVK04U Owner: S -et "s Date of Inspection: U t Check if the following have been done You must ind-cate either "Yes' or as to each of the following Yes NO X _ Pumping information was provided by the owner• occupant, or Board of Health hone of the s%-stem components have been pumped for at least rwo we-eks and the sys:em has been rece, ing norrra floN (ales during that period large volumes of water have not been introduced into the system recen:l� or as pan of this ,nspectior. _ As b-id:.pians ha\e bee oo:amed and exa-.:ned Note if the) are rot a%ailable With WA The iaC"l,r� at 6 elhng as insDecled (a, signs a' sewage bad-up Tne system does not rece•,e non•sanitan or indus;naf waste flow i — Tne site %%as insoecie; for signs of brea:ou: A.I s\ste- co •pcne^t;. ekcludrn¢ the Sc.' Aesdrpvcn 5�"S:e.^••, have beo (CUied cn ire site ` The seC:•c talk C.a'•^.C-e• Me•e_unco%ereC. coened. and the interior Of tie septic tank v.aS irsaecieC ic• c0+'d•t,cr. 0; bacies or tees, r-.a:er•a o• construc-on. c:rrens.ons. cev-n of liquid, depth of sludge. ceCth of scum j — Tne size aid toca: c,• c- t"•e So.!'!.t5Orp:;Cn S\s:er" on t^e site has been determined basr+ on - Tne tac•i,h O,•ne• •a'C occurants is direren: from o�nett »ere provided with inior•:,a;,en on tie ca:^te"a^ce of i Sub Su`ace D'spesal S%s:e r Exis:-rg in-o•-a;ror• E-- P:a^ r. E O H — De:e•rn-ec ir. the i,e;d i• an% o'the a: ure C'';e•.a reiated tc Pa•^. C is a; issue, n.-ioximx.on c' ur•acce.:aa a (t 3 302 3 'c t i 'i ,e r . ).g• 4 of 10 F ; SUBSURFACE SEHAGE DISPOSAL S1 STEM IN SPEC TIO%JORMI-A- PART A CERTIFICATION (continuedt Propert► Address: Owner. G Date of Inspection: t e DI SYSTEM FAILS: I You must tndlc�ale either 'Yes' o' 'NO' at to each of the folloM'rng I have determined that the system s,olaies one or more of the following failure atte•ta a: defined In 310 CMR 15.303 Tne Dose for this oetermination Is rdent,iied below.. The Board of Health,should be contae,ed to determine what will be necessan 10 cortex i the failure Yes No c — _ Backue 01 selvage into fa0 ^,,or ss_s;e-,+ component due to an overloaded or clogged S^S or cesspool — _ Discharge Or pond,ng of eHluentrto the surface of the ground or surface wate•s due to an over►oided.or,ciogged SAS or !! Cesspool f[ tF& S:a:ic trcu,d leve' in the detrnbil,on Co% a,o`e outlet invert due to an overloaded Or 009see SAS Or'CesSD00! Licuid Oe;::' it cesspoo- is less Iran 6" below invert or ava-labie volume is less than 112 day flo`. • Recu-rec cump.ng more tha,• 4 time! in the last year NOT due to clogged or obstructee pipe s r,.umcer o,time! pur"ped {' An. por1,On 0' the .Oa Ap5c';tocn S%stvr. Cesspool or priv',- is below the high groundMate- e;evatior• An, cC-�.On 0: a Ce!.C;001 Or P"%-\ IS MilniG 100 tee! of a surface wa'e' succi% or Vibuta'%.10 a sundce Mate' suppi5 Anl por•ion o: a Ce'.scoo ror pri%1 is v.ithir•'a Zone I Oi a public well - { Any pc'ic' c' a ceSsDOo: 0- prig•, I$ �+::^. n 5C fee' Or a ,rtva:e wate' Sc�p'� we! - Y • An o a cesspool e' D'`: is less o an. 10C fe-'.bu: g'eate' inan So ie!: irc-r a pri\ylt Mote' SucD v well with no has been array:ed to be accec:at e. aracn ccc` ci we l Maser analyse for coloorr. taee':a `c:a:ile cr€a-C CC-;OundS, ammOn.a nitrogen and nitrate;nrlr0¢e l • FAILS: - E; LARGE I 1 ou mus: ind.cate a:,e• "Yes o .-NC as to eac`+ o: the fe'loMir.g The ic::oj c re a a�;) ` lc :a•ge syste'f s Ir. acoltion to the criteria at_o e It The system se�es a iacilm with a desig- floM Oi 10.000 gad or greater (Large System.,. ane me systern is a s.gnifrcant threat to public health and sa:eq:and the envircir.ment because one or more of the following conditions exist h , l es NO the system is within 400 feet of a surface drinking water supply the system'. is within 200 feei of a tributary to a-surface drinking water supple the syslerr is located in a nitrogen'sensitive area.(Interim Wellhead Protecxion Area •.IWPA) or a mapped Zone II of a public water supply well) <. The owner'or operator of an) such system shall bring the systern and facility into full compliance with the groundwater treatment program requirements of 31. CMR,5 00 and 6 00 Please consult the local regional office of the Department for further tniormatton. s J ("rtivlo*d 04/35/1'•l Page 3 of 3: r SUBSURFACE SEw'AGE DISPOSAL S"rSTEm I\SPECTIO\ FOR�t; PART C , SYSTEM ItiiORMATIO\ [continued Propem Address: i7/9 OM net: Date of Inspection: M5��$ v k a - TIGHT OR HOIDI\G TANK: ank mus: be pumped prior to. or at ;,me, of Inspe^.ion (locate on site plan, Depth below grade malerlal of construction _concrete _me:a: _FIberg.us Poiyethylene'_cthe•,explal , , Dimensions Caoacln gallons Desq- floM gallo^sca• `- A;arm leve, 'p•a.ng o•ce• Les NC Da'e or pre%sous pu"Ip'ng = + R Comments tcond*or. Cf Inle! tee Conc.;ic . o- a'awrr a;- f1ca: sAitcheY etc DISTRIBI,'TIO♦ BOx.c�-(� M. occa:e on sl:e c a- , c' Ic.,'c ,e,e aco.e o..•-e In•e' - `ti�0 � t �� Ino:e leie- a-.c c s:'IcJ: of, Is.PC:uc ,gee^ a c' sol.cs carr.o%e' e%Iden o: leakage Int or.out bo e:C I l r 4 PUMP C.MA,MBER.Aio I n I I n' ( ovate o site p a Pumps In working order IN es or no Y /:awns in working-order O es or hp Comments. (note condition of pump chambeP-':condition of pumps and appurtenances, et ' Irav��ad Of/1s. f.I' + layer 1 of 1J R j Lt L� Irtl war , • _ _ .- £ < ' SUBSURFACE_SE�%ACE DISPOSAL SYSTEM ItiSPECiIO% FORI-t PART C 11 SYSTEM INFORNiAT10% (continued) Proptrtl Address OM'ner: �S r Date of Insptulon. SOIL. ABSORPTION SYSTEM ISASI:�,Gs ^ tlocate on site plan, it possible, e%ca�a/hon not required. but maN• be approxi,a:ed by non-intrusive rnetnoas• If not determined to be present, etpla f • T1'pe t; leaching pits. number `DX� f leaching chambers. numpe leaching gallefies..nurrbe (G leaching trencnei. numbe,.length n .• , leaching i,e�G5. nu-1W �! overdo.. cesspool. numoe ^hernative s%sterr' w name of Tecnnotog•. 7 Comments - r h.c a : c fai!.:•e. !e•e o' pc,d.ng' c .d;rc r eIt , t on. etc t 1 mote condmo- o' sc •g^s e� - `rSigM fl CESSPOOLS: Z� i occate on site p!a- i. r.umbe• and cc,.nl;.,•a'c- r I; Dean-too of IIc.,,c to in,er. Deptn of solids lave Depth of scum lave, „ • . Dimensions of cesspoo mate,tals of construc;,o Indication Of grOuncNate' , d lnfloN tcess000� —s: oe•o.;-n+,ec as Da' or rnspe..:o ' Comments mote condition of soil, signs of hj•draulrc failure, le%e!4of pondmg. condition of vegetation, etc-) r < • L PRIVY z' !locate on site'plan! r Dimensions wtaterials of construci on • Depth of solids 3 ' Comments ' !note condition of soil, signs of h.•dravl,c failure, level of pondmg, condition of vegetation, etc I �« li•v:1�G 0�;13/f•1 ),�y••�f of :0 - .. e 9 k SUBSURFACE SEWAGE DISPOSAL SYSTEM IhSPECTIO*� FORM ; PART C SYSTEM INFORMATION (continued. Property Address: Owner: - - _ Date of In,pectlon: t SKETCH OF SEw'AGE DISPOSAL SYSTE%%. Include ties to at least Mo pe,ma0ent rele+ences landrturis or benchrnafls�,= ;r ' 1' locate'all Ne'is M,thln 100 (Locate Mhele pubic Matti supply comes Into house I • rt 3 o 3 v w : r pp ! • Y . ., • .. :� • � T ,. •'. is ` ,f M kT .�:.�5 0• f5 4:. f of 10 ^ . r SUBSURFACE SEWACE DISPOSAL SYSTEM 1%. SPECTION FORM PART C SYSTE.m INFORWITION (continued) Propert% Addrev• ee�� '. I Owner: NN`e✓ 31s f In i e u too s enn u Dept''• to Cround�ate• Fee: Please indicate ]!I the methods used to de_e,-,ne Hig^ Cfound�a!e' Elevation Obtained !room Design Plans on retort _ •^ no,e base-ent"sump e'. , ]!gyp . GbSC�]tiC"• 0 Site tAoyn,n6 prpper'1 ot)le i .. Deterrrime it irom local conda,onl Cne�. %.qn IOCa" S:,arc p Cne,. F;MA n*.aC! e Cnec, p.;-v.nF reco•cS t Cnec�, loco' e.a.a;o s ins:a!!e Ges. _, ,c_ c• _ c_ es a=':-e P r -. N �(m.u%! be,corn: e�'e�C ;T,o�1�5�o s' _ 'i • v �. . �� . _ .. � as: .. ' y y « •. * ._ ,_Wry {, - r -t c- .a i SLBSURfaCE S(%%AGE DISPOSAL SYSTE.tit I%,SPEC710\ FORM PART C SYSTE-s I\FORMATIO% (continued. Properis Address:' 0%ner: Date of mpection: 31J' 1 BUILDING SEWER: (Locate on site plant Depth below grade Material of construciron — cast 'ion _ 40 PVC = other texolarn, ' Distance from private water suook well or suC�on L-• _ . Diameter Comments icondrlion of joints, venting, evidenCl,Oi leakage 'etc., j SEPTIC TANK:—q6 (locate on site plan - - grade � r a!! �c �ltnvlene o:nl,.e.0ia• N Deo;h below g y nta;er.al o: construct o^ 4C0r%cre•e —r.e.i — OP'g. — — n iIt tan. is meta: IIs*. age 1S age co-7 irntc L• Ce-.t-ca:e o-. Compnance es No D,mens,ors gip` Slucge deoth y D,siance irorr• top c s'ucee to bono o- c.,:;e- tee o• ba=a _ �r scum thickness�_ an Distance from tot) o' scurn 10 tco c• 0.::te: tee c ba" a _ Distance iron —bono•r 0' sci 10 ec-=— 0• o.,ae! t e c ca-e 1�y r-.cw dimensions we•e ae:e,rninec l COmmentS �. r 'ir•e' a"c a.a•e'� le-S Or.Catire5. de):'. 0: I�Cv�d le•e:-rn re+]LOn IO ulle: rnveR, sSruCut]l i; trecoT.menda;.on icr pumping cc"c•, .;- c• _ t U irneg,,-: e,science o' lea�aee. e: N H II i� n T- It GREASE TRAP: ;i docate on site plan a (t Death below grade nta;er al of construction concrete . metal Frbe•glass _Polyethylene _otherte=olainl, If — — — Dimensions. Scum thickness: Distance from top of scum to top of outlet tee or baffle Distance from bonom of scum to bonom of outlet tee o bafite Date of last pumping Comments: trecommendation for pumping, condition of rilet and outlet tees or baffle. depth of Liquid level in relation to outlet invert, structural ;ntegrltl, evidence of leakage. etc : 1:..•:i.e 0a.'3'..'f'1 ... page 6 of 11 l , , SUBSURFACE SEWAGE DISPOSAL SYSTEM I\SPECTIO\ FORM PART C. SYSTEM INFORtitATIO\ Properts Address: Owner: S1 TN/- S Date of Ihspection: 3ISI I� i , F r FLO."' CONDITIONS RESIDENTIAL Design iiow �'D R o d bedroo r io! S4� 5 Number of bedrooms .Q.3 Number o• current resicenls Garbage g'. der (yes or no- Laundry co•"^erred to system (yes or no _ Seasonal use Ives or no Water meter reading$. if a� ilabie Ilas: rAc ,_ vea' usaee tgx.` �g ysQ Sump Pump Ives or nor ,, La'. da:e c' occupancy S�•(J{2�S^.J. ',:T COMMERC i 8,L'INDUSTRIAL Type of establishment Design ho\. abonsaa� C, Creme trap present ryes or no �. Inc.:s:r,a' 1%aste holding Tani, ore5en; -%es or nC ':Jn•Sd^..ta'\ Naste d.scnarge-z to the 7,',n j�e-r ;%ec p?no '.ate• meter reac'.ngs if a'.a.labie Las'rate e' c ._:2nc•. OTHER.. :)e:c•rbe Las: case or occ,;calc. r - .4 ' C,E ,ER.AL I%FOR.titATIO♦ A PU.MPI\G RECORDS an. r i ini ,d source o c -r,a:�o- . Nw Y1 Q l iV1(1 S x'ew nnn t0 t S%slem pumper as par of rnspee1077. ;%es or no If ves. �-o.ume pumped Yallons Reason for pu-noing, TYPE OF SYSTEM ASept-c tanl,.rd-stribution boxr'soil absorption system Singe cesspool OvenloM cesspool Pri.) t v' Snared system (yes or no! (if yes•.arach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE 'AGE of all,components. date installed (if known) and source of information Sewage odors detected when arriving at the srie cues or not } lz�.•:i:C C�•'25/)'; Pal; 5' o: 10'_' . . Ll a. TOWN OF BARNSTABLE�,��` I 6CATION L®+ VILLAGE ` S -8&4"L54(-ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. -•J. 'Q(:S Cd\( 7W- 1 D q 0 SEP11C TANK CAPACITY 00 0 �+� LEACHING FACILITY:(type) �'�'� (size) ( ,d Oda��Ot,; . NO. OF BEDROOMS � PRIVATE WELL O PUBLIC WAT�ERJ BUILDER OR OWNER �7� I j y 6(�`�•y_ C6, . DATE PERMIT ISSUED: fa-.?t9 - Ld & DATE COMPLIANCE.ISSUED: VARIANCE GRANTED: Yes No Co � �` s 1 1 i 4 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOTo,fV-a4 Dd 3 INSTALLER'S NAME & PHONE NO. %v SEPTIC TANK CAPACITY O LEACHING FACILITY:(type) (size) Jo-� NO. OF BEDROOMS PRIVATE WELL OkjUBLIC WAS BUILDER OR OWNER DATE PERMIT ISSUED: %G 2.26 G DATE COMPLIANCE ISSUED: // - 2 S� $ 7 VARIANCE GRANTED: Yes No,001,110-11, �o �a '�C6